(Archived) Manager of Care Management

Job Summary:

Responsible for the day to day operations of facility wide utilization, discharge planning and care coordination.

Qualifications:

• Preferred Education: Master’s in Nursing or Masters in Social Work or related
• Preferred Licenses/Certifications: Certification in Case Management, CCMC or
• Required Experience: Five years of clinical nursing experience in a directly related setting (e.g., acute care, skilled nursing, etc.); three years of case management experience; two years of supervisory or lead experience.
• Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California or licensed in Clinical Social Work in California, Active BLS - Basic Life Support Certification issued by the American Heart Other advanced life support certifications may be required per unit/department specialty according to patient care policies. CPI -Crisis Prevention Intervention Training.

Knowledge, Skills & Abilities:

• Act in an appropriate and professional manner as defined by the company’s Standards of Behavior, Policy and Procedures, and Scope of Services.
• Role model AHS Standards of Behavior.
• Proficient computer skills including Microsoft Office (Word, Outlook, Excel, PowerPoint).
• Current office administrative practices and procedures.
• Correct business English, including spelling, grammar and punctuation.
• Use independent judgment and initiative within established policies and procedures.
• Establish and maintain effective working relationships with a variety of individuals from various socioeconomic, ethnic and cultural backgrounds.
• Excellent communication skills, both written and verbal.
• Strong managerial skills, including coaching and mentoring, problem solving, conflict resolution and motivational skills.

• Exceptional interpersonal skills required for connecting with patients and their families as well as successfully interacting with referring physicians and community organizations.

• Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities.
• Extensive knowledge and complete understanding of Case Management, regulatory requirements, third party payor criteria and critical time lines.
• Excellent critical-thinking and analytical skills. Utilizes professional judgment and critical thinking to assist staff in working with members in overcoming barriers to goal achievement.

• Knowledge of medical terminology, treatment modalities and trends in social case/nursing work.
• Understanding of care planning interventions which includes but not limited to care coordination planning, nursing assessment, and biopsychosocial assessment including assessing patient’s social network needs and family interventions.
• Knowledge of standardized Interqual® or Milliman Care Guidelines.
• Experience with Electronic Health Record (EHR) and Case Management applications, e.g. Midas or3M.
• Knowledge of program planning and evaluation techniques and strategies.

• Knowledge of the TJC, DMHC, CMS, NCQA, HIPPA, ERISA, EMTALA & all other applicable federal/state/local laws & regulations.

Physical Requirements and Work Environment:

• The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Activity: Sit: Continuously (more than 2/3 of the work shift)
• Activity: Stand: Occasionally (up to 1/3 of the work shift)
• Activity: Walk: Occasionally (up to 1/3 of the work shift)
• Motion: Bend/Twist: Up to 1/3 of time
• Motion: Carry/Lift: Up to 1/3 of time
• Motion: Reach: Up to 1/3 of time
• Motion: Squat: Up to 1/3 of time
• Use of Hands (Left/Right): General Motor Function
• Use of Hands (Left/Right): Precise Motor Function (Or Fine Manipulation)
• Use of Hands: Repetitive Motion: 1/3 or more of time
• Weight Lifted/Force Exerted: Up to 10 lbs: Up to 1/3 of time
• Work Environment: Special visual or auditory requirements including working with a computer terminal.
• Work Environment: Tasks involve no exposure to blood, body fluids, or tissues.

FLSA Status & Representation:

• FLSA Status: Exempt
• Representation: Unrepresented

Job Responsibilities:

• Manages and assumes responsibility for day to day operations of utilization management, care coordination and discharge planning activities.
• Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of care management clinical and administrative staff.
• Reviews cases regularly with staff; acts as clinical consultant regarding care management issues; guides clinical staff with review of assessments and care plans, evaluates utilization reviews or documentation
• Serves as a content expert to staff and internal departments and external partners; networks with other hospitals, nursing organizations, and professional organizations to keep abreast of changes within the profession.
• Oversees submission of any audits, including but not limited to MediCal, Medicare and internal compliance studies.
• Performs daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and Interrater Reliability).
• Conducts interdepartmental team conferences for identifying aberrant utilization; establishes a method of tracking variances based on critical timelines.
• Assists Director in establishing, implementing and ensuring that care management policies, practices and procedures are in accordance with the Joint Commission, Title 22 and other regulatory agencies and overall hospital policies.
• Direct and coordinate data gathering and record keeping legally required by Federal and State agencies, the Joint Commission, and hospital policies; participates in the risk mitigation, process of implementing new or revised processes, and projects.
• Manages process of pre-admission review of questionable admissions as referred by Admitting, Emergency Room and medical staff and offers workable solutions.
• Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals. Maintains minimal denial rates by Medicare, MediCal, private and contracted payors through appropriate direction of utilization practices; assists physicians and hospital personnel in understanding care management issues.
• Provides in house educational programs as needed for both staff and physicians.
• Develops and provides statistical UM information and reports to appropriate committees and in conjunction with the Director of Care Management identifies utilization issues affecting the quality of patient care.
• In conjunction with VP and Director, coordinates, develops, and implements action plans to respond to areas felt to be in need of improvement related to patient flow and care coordination across the continuum.
• Prepares cost analysis reports and other data needed for the preparation of the departmental budget.
• Responsible to purchase, educate, and record education to new equipment and/or techniques.
• Conducts and records periodic staff meetings, to inform staff of changes in policies and procedures.
• Supervises technical procedures and performs procedures as needed.

• Perform all other duties as assigned.

Job Summary:

Responsible for the day to day operations of facility wide utilization, discharge planning and care coordination.

Qualifications:

• Preferred Education: Master’s in Nursing or Masters in Social Work or related
• Preferred Licenses/Certifications: Certification in Case Management, CCMC or
• Required Experience: Five years of clinical nursing experience in a directly related setting (e.g., acute care, skilled nursing, etc.); three years of case management experience; two years of supervisory or lead experience.
• Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California or licensed in Clinical Social Work in California, Active BLS - Basic Life Support Certification issued by the American Heart Other advanced life support certifications may be required per unit/department specialty according to patient care policies. CPI -Crisis Prevention Intervention Training.

Knowledge, Skills & Abilities:

• Act in an appropriate and professional manner as defined by the company’s Standards of Behavior, Policy and Procedures, and Scope of Services.
• Role model AHS Standards of Behavior.
• Proficient computer skills including Microsoft Office (Word, Outlook, Excel, PowerPoint).
• Current office administrative practices and procedures.
• Correct business English, including spelling, grammar and punctuation.
• Use independent judgment and initiative within established policies and procedures.
• Establish and maintain effective working relationships with a variety of individuals from various socioeconomic, ethnic and cultural backgrounds.
• Excellent communication skills, both written and verbal.
• Strong managerial skills, including coaching and mentoring, problem solving, conflict resolution and motivational skills.

• Exceptional interpersonal skills required for connecting with patients and their families as well as successfully interacting with referring physicians and community organizations.

• Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities.
• Extensive knowledge and complete understanding of Case Management, regulatory requirements, third party payor criteria and critical time lines.
• Excellent critical-thinking and analytical skills. Utilizes professional judgment and critical thinking to assist staff in working with members in overcoming barriers to goal achievement.

• Knowledge of medical terminology, treatment modalities and trends in social case/nursing work.
• Understanding of care planning interventions which includes but not limited to care coordination planning, nursing assessment, and biopsychosocial assessment including assessing patient’s social network needs and family interventions.
• Knowledge of standardized Interqual® or Milliman Care Guidelines.
• Experience with Electronic Health Record (EHR) and Case Management applications, e.g. Midas or3M.
• Knowledge of program planning and evaluation techniques and strategies.

• Knowledge of the TJC, DMHC, CMS, NCQA, HIPPA, ERISA, EMTALA & all other applicable federal/state/local laws & regulations.

Physical Requirements and Work Environment:

• The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Activity: Sit: Continuously (more than 2/3 of the work shift)
• Activity: Stand: Occasionally (up to 1/3 of the work shift)
• Activity: Walk: Occasionally (up to 1/3 of the work shift)
• Motion: Bend/Twist: Up to 1/3 of time
• Motion: Carry/Lift: Up to 1/3 of time
• Motion: Reach: Up to 1/3 of time
• Motion: Squat: Up to 1/3 of time
• Use of Hands (Left/Right): General Motor Function
• Use of Hands (Left/Right): Precise Motor Function (Or Fine Manipulation)
• Use of Hands: Repetitive Motion: 1/3 or more of time
• Weight Lifted/Force Exerted: Up to 10 lbs: Up to 1/3 of time
• Work Environment: Special visual or auditory requirements including working with a computer terminal.
• Work Environment: Tasks involve no exposure to blood, body fluids, or tissues.

FLSA Status & Representation:

• FLSA Status: Exempt
• Representation: Unrepresented

Job Responsibilities:

• Manages and assumes responsibility for day to day operations of utilization management, care coordination and discharge planning activities.
• Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of care management clinical and administrative staff.
• Reviews cases regularly with staff; acts as clinical consultant regarding care management issues; guides clinical staff with review of assessments and care plans, evaluates utilization reviews or documentation
• Serves as a content expert to staff and internal departments and external partners; networks with other hospitals, nursing organizations, and professional organizations to keep abreast of changes within the profession.
• Oversees submission of any audits, including but not limited to MediCal, Medicare and internal compliance studies.
• Performs daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and Interrater Reliability).
• Conducts interdepartmental team conferences for identifying aberrant utilization; establishes a method of tracking variances based on critical timelines.
• Assists Director in establishing, implementing and ensuring that care management policies, practices and procedures are in accordance with the Joint Commission, Title 22 and other regulatory agencies and overall hospital policies.
• Direct and coordinate data gathering and record keeping legally required by Federal and State agencies, the Joint Commission, and hospital policies; participates in the risk mitigation, process of implementing new or revised processes, and projects.
• Manages process of pre-admission review of questionable admissions as referred by Admitting, Emergency Room and medical staff and offers workable solutions.
• Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals. Maintains minimal denial rates by Medicare, MediCal, private and contracted payors through appropriate direction of utilization practices; assists physicians and hospital personnel in understanding care management issues.
• Provides in house educational programs as needed for both staff and physicians.
• Develops and provides statistical UM information and reports to appropriate committees and in conjunction with the Director of Care Management identifies utilization issues affecting the quality of patient care.
• In conjunction with VP and Director, coordinates, develops, and implements action plans to respond to areas felt to be in need of improvement related to patient flow and care coordination across the continuum.
• Prepares cost analysis reports and other data needed for the preparation of the departmental budget.
• Responsible to purchase, educate, and record education to new equipment and/or techniques.
• Conducts and records periodic staff meetings, to inform staff of changes in policies and procedures.
• Supervises technical procedures and performs procedures as needed.
• Perform all other duties as assigned.